To print this form, right click on the page and then print. Send to address at the bottom of application.
​
Caring Canines Therapy Dog Club of Southern Vermont
Application for Membership
Regular Member ($35.00) Household Membership ($50.00) Supporting Member ($20.00)
Payment of dues will be collected upon successful completion of dog/handler evaluation. Evaluation fee $25
Name:________________________________________________________________________________
Address:______________________________________________________________________________
City / State/ Zip :________________________________________________________________________
Telephone: _________________________________ Fax: ________________________________________
E-Mail: _______________________________ Breed of Dog:______________________________________
Name: ___________________________________ Date of Birth:___________________________________
Sex: _____________________________________ Color:________________________________________
Number of Dogs in the household _________________ Is your dog spayed / neutered? Yes No
In order to help us better understand you and your dog, please complete as much of the information below as you are comfortable with. If not applicable, please indicate with ‘NA’
How did you become aware of Caring Canines?__________________________________________________
_______________________________________________________________________________________
List other clubs to which you currently belong:___________________________________________________
_______________________________________________________________________________________
On what club committees have you served and/or what club related activities have you been involved with?___
_______________________________________________________________________________________
List any dog related areas of interest:__________________________________________________________
________________________________________________________________________________________
If accepted as a member of the C.C.T.D.C. of S.VT., what would you most look forward to?________________
________________________________________________________________________________________
What is your perception of a therapy team and tell us what type of visits you are interested in doing? (Nursing home, Adult Day Care, Children’s Reading Program, Animal Assisted Therapy, Other.) Can you commit to at least 5 visits a year? _____________________________________________________
________________________________________________________________________________________
Why do you believe that your dog is suited to therapy work: _________________________________________
_________________________________________________________________________________________
List any activities that your dog has participated in:___________________________________________
_________________________________________________________________________________________
Does your dog have a Canine Good Citizen certificate (CGC)? ______________________________________
Describe the level of your dog’s obedience experience: ____________________________________________
________________________________________________________________________________________
Has your dog ever bitten a human being? Yes No
Is your dog hand shy? Yes No
Has your dog ever been involved in a dog fight? Yes No
Is your dog shy or nervous around crowds of people (describe):______________________________________
________________________________________________________________________________________
Does your dog get along well with children (describe)?___________________________________________
__________________________________________________________________________________________
How does your dog act with multiple dogs and people in the room?_____________________________________
_________________________________________________________________________________________
How does your dog handle stress (describe):______________________________________________________
_________________________________________________________________________________________
What do you do as a handler to address this?_____________________________________________________
_________________________________________________________________________________________
What types of collars and leashes do you use?_____________________________________________________
__________________________________________________________________________________________
Describe you dog (check all that apply):
Adaptable Outgoing Timid Shy Hyper Friendly Calm Reliable
Are you interested in participating in workshops offered by Caring Canines?_______________________________
_________________________________________________________________________________________
Do you belong to another Therapy Dog organization? If yes which one: ______________________________
Signature of Applicant _________________________________________ Date _______________________
Please mail completed application to:
Lisa Cacciatore
1330 Pencil Mill Rd.
Castleton, Vt. 05735
